Despite a great deal of attention in recent years, the issue of some black men keeping their bisexual behavior secretive from their main female sex partners, or “keeping it on the down-low,” does not translate to high-risk sex with male partners, nor an increased risk of HIV transmission, according to David Malebranche, assistant professor of medicine in the School of Medicine and internist at Grady Hospital.

Malebranche is co-author of a recent review article with Gregorio Millett, Byron Mason and Pilgrim Spikes, all from the CDC. The results of the review, “Focusing ‘Down-Low’: Bisexual Black Men, HIV Risk and Heterosexual Transmission,” appear in the July issue of the Journal of the National Medical Association. The article is the first of its kind to critically examine the “down-low” theory—that secretive black bisexual men are the primary force behind the current high rates of HIV among black women in the United States.

Using statistical data compiled from 24 reference articles, two conference abstracts and literature about bisexually active men of all races and ethnic groups, the authors examined four key points: estimates of bisexuality among black men; identity versus behavior—or what men call themselves versus how they behave sexually; rates of same-sex behavior disclosure among black men who have sex with men (MSM); and whether nondisclosure of same-sex activity translates to riskier sex or decreased condom use.

According to the article, the best available studies actually report a low prevalence of bisexual behavior
(2 percent) among black men in the United States. The authors also found that when compared to white, Latino and Asian MSM, black MSM were more likely to identify as bisexual or report being behaviorally bisexual, and were less likely to disclose their same-sex behavior.

The authors found studies, however, reporting that nondisclosure of same-sex behavior did not lead to riskier sexual behavior. One such study described that black MSM who did not disclose their homosexual activity were less likely to be HIV positive, have multiple male sexual partners, or have unprotected sex with male partners than those who disclosed their same-sex behavior.

“The purpose of the paper was to examine four major points commonly made when talking about the down-low and to see how much those issues actually played out in the literature and data,” said Malebranche, who also practices at Atlanta’s Ponce de Leon Center, one of the largest outpatient clinics in the country providing comprehensive medical care to approximately 4,000 HIV-infected patients each year.

“What we found was that while the prevalence of bisexuality among black men in general appears to be low, reported bisexual identification and behavior among black MSM is a lot higher than other ethnicities, and they are not as likely to disclose their same-sex behavior as white MSM,” he continued. “However, when it comes to unprotected sex, it appears that nondisclosing black MSM engage in less risky behavior than those who disclose their same-sex behavior.”

Based on those findings, Malebranche said it’s erroneous to believe that bisexual black men on the “down-low” are disproportionately responsible for transmitting HIV to heterosexual black women.

“When you look at the whole issue of what down-low means, it really translates into the issue of disclosure—who you’re telling and who you’re not telling—and may be dependent upon the nature of the relationship and gender of the individual with whom you’re having sex,” Malebranche said. “If some black MSM are secretively bisexual, studies have demonstrated that they’re more likely to have more female partners than disclosing black MSM, and thus are more likely to have unprotected sex with these female partners. However, these same men report lower rates of unprotected sex with their male sexual partners than disclosing MSM.”

These facts lead the study team to ask, “If bisexual black men represent a small proportion of black men in the United States, and nondisclosing black men are less likely to be HIV positive than gay-identified men or engage in high-risk behavior, then is this population primarily responsible for the HIV epidemic among heterosexual black women?”

According to recent statistics, approximately 40 percent of the cumulative AIDS cases among black women through 2003 are attributable to intravenous drug use, with another 40 percent attributable to risky sexual behavior. However, it’s not known what proportion of these cases are infected through having sex with heterosexual, bisexual or homosexual men.

“The flawed logic often perpetuated by the media is that only homosexual men have HIV, bisexual men only contract HIV through homosexual behavior, and the only way black women contract HIV is through sexual contact with these bisexual men,” Malebranche said. “Homosexuals are not the only ones with HIV, and just because someone keeps their same-sex behavior secretive doesn’t necessarily mean that they are irresponsible with condom use.”

The authors argue that the issue of high-risk sexual behavior among heterosexuals has been absent from the discussion involving men on the down-low and the high prevalence of HIV among black women. For instance, they found that rates of condom use by black heterosexuals are low, even among couples, where one partner is HIV positive and the other is HIV negative.

“Subscribing to the down-low theory takes the focus away from the behavior that transmits HIV,” Malebranche said. “As a society, we have to think deeper and more critically about what the reasons are for the high rates of HIV in our community. We hope this article facilitates or at least stimulates critical discussion about this topic because there’s still a lot we don’t know.”